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• r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: L � J, Page of N Facility Address: City: r-sco-Tr / Inspe io at v7 FA #: PR M 3 Program Element: 2971 5 D Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. ©'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 06/�r3%q� 1Product Total Capacity: .3 �o gallons Type: 121L"1� (per tank or cumulative for containers by product type) Install Date: C�k (2820) 11 Containers (2821) #of Containers: _ TA#: 2 Total Capacity: S� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: �ank (2820) El Containers (2821) #of Containers: /#: 8' 3 Total Capacity: grid gallons Product Type: (per tank or cumulative for containers by product type) Install Date: a --rank (2820) ❑ Containers (2821) #of Containers: TA#: 4Product Total Capacity: � J-"� gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: b gallons Total Capacity for Site: or) gallons Comments: Zcb 0 EHD Inspector: Reviewed ` _l Date: By Initial: �v Q , ti� '� Entered Date: By Initial:V0 � �qL *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08